Resolution of Migraine with Aura Post-PFO Closure in a Young Female: A Case Report

Introduction

Migraine with aura is a complex neurological disorder marked by distinctive visual, sensory, and motor disturbances that often precede or accompany headache episodes. These aura manifestations, lasting from 5 to 60 minutes, encompass a range of symptoms from visual disruptions like flashing lights and zigzag patterns to sensory and speech impairments [1–3].

Concurrently, patent foramen ovale (PFO), a prevalent cardiac anomaly, is increasingly implicated in the etiology of migraines, especially those accompanied by an aura. This condition is of particular concern in younger individuals due to its association with an elevated risk of ischemic stroke and its prevalence in cryptogenic stroke (CS) cases, where PFO-mediated paradoxical embolisms are considered a significant causative factor [4–9].

Despite PFO being present in approximately 25% of the global population, its clinical implications often remain underrecognized, manifesting in transient ischemic attacks (TIA) or strokes that patients may not immediately associate with their migraine history. This oversight underscores healthcare professionals’ need to consider PFO in the differential diagnosis of young migraineurs presenting with aura, advocating for diagnostic procedures like echocardiography to detect PFO presence [10].

This case report is particularly enlightening due to the patient’s proactive engagement in comprehensive diagnostic evaluations, facilitating timely PFO closure and averting potential stroke risks. Highlighting the migraine with aura and PFO linkage underscores the critical role of tailored medical interventions in enhancing patient outcomes, emphasizing the importance of a multidisciplinary approach in managing such complex clinical scenarios [10].

Case Report

TIMELINE:

July 2023: MRI/A (Figure 1); EEG; Holter, August 2023: TEE; Bubble test (Figure 2), Dec 2023: PFO Closure (Figure 3).

Discussion

The discussion of the interplay between migraine with aura and patent foramen ovale (PFO) necessitates a nuanced exploration, given the complex pathophysiology underlying both conditions. Migraines, particularly those accompanied by aura, present a multifaceted clinical challenge characterized by a spectrum of neurological symptoms preceding the headache phase, including visual disturbances and sensory alterations [11]. The etiology of migraine aura is believed to involve cortical spreading depression, with a wave of neuronal and glial depolarization across the cortex, which may be influenced by various external and internal factors, including hormonal fluctuations and dietary triggers [12].

PFO, a remnant interatrial communication that persists post-natally in approximately one-fourth of the population, is generally asymptomatic [13]. However, its role in paradoxical embolism has been shown in cryptogenic stroke and, intriguingly, in the pathogenesis of migraine with aura. The hypothesis that microemboli traversing a PFO might precipitate migraine attacks, possibly by triggering cortical spreading depression or through other vascular mechanisms, remains a topic of ongoing research [14].

The present case exemplifies the clinical dilemma of refractory migraine with aura in the context of a diagnosed PFO, prompting consideration of interventional closure. Several diagnostic methods are used to diagnose PFO. TEE is a widely available and commonly used technique for detecting the presence of a PFO. TEE is considered the criterion standard for diagnosing PFO, as it provides a more detailed assessment of the cardiac anatomy and the presence of any intracardiac shunting. TEE provides a comprehensive evaluation of the presence, size, and characteristics of a PFO and also describes the precise location and size of the patent foramen ovale, as well as the presence of any right-to-left shunting [15]. Bubble contrast echocardiography is another useful diagnostic tool that can help identify and quantify the degree of right-to-left shunting through a PFO. In addition to echocardiographic evaluation, other imaging modalities, such as transcranial Doppler ultrasonography and cardiac magnetic resonance imaging, may also play a role in the assessment of PFO and its potential associations with neurological conditions like migraine with aura. MRI and CT imaging modalities can also be utilized to visualize the cardiac anatomy and identify the presence of a PFO. MRI describes the anatomic features of PFO with high resolution that can be valuable in clinical decision-making [16,17]. Percutaneous closure of PFO has shown promise as a treatment for migraine in patients with PFO. However, a potential concern with this procedure is the use of fluoroscopy, which exposes patients and healthcare professionals to ionizing radiation. In recent years, there has been a growing interest in developing a non-fluoroscopic approach to percutaneous PFO closure in migraine patients. This approach aims to minimize radiation exposure while still successfully closing the PFO. In this case, we decided to proceed with percutaneous PFO closure using a non-fluoroscopic approach [18], reflecting an innovative adaptation to reduce procedural radiation exposure. This technique aligns with emerging trends toward minimizing fluoroscopy in interventional cardiology, supported by evidence suggesting comparable success rates to traditional fluoroscopic methods. Ewert et al demonstrated the feasibility and safety of the non-fluoroscopic approach, further supporting its use in reducing procedural radiation exposure in PFO closure procedures for refractory migraine with aura. Another study compared the outcomes of percutaneous PFO closure using a non-fluoroscopic approach versus a traditional fluoroscopy-guided approach. The results showed that the nonfluoroscopic approach successfully achieved complete closure of the PFO in all patients, with no complications reported and without the need for fluoroscopy, minimizing radiation exposure. This approach offers a promising alternative for migraine patients undergoing PFO closure, reducing their radiation exposure and potentially improving the overall safety of the procedure [19–22]. Additionally, the use of a non-fluoroscopic approach may improve the overall safety of percutaneous PFO closure in migraine patients, as it eliminates the potential risks associated with radiation exposure. It is important to note that current evidence does not support PFO closure as a treatment for migraines. However, in cases where PFO closure is warranted for other medical reasons, a non-fluoroscopic approach may be a beneficial alternative to reduce radiation exposure.

The notable improvement in migraine symptoms following PFO closure in this patient adds to a growing body of anecdotal and research findings suggesting a therapeutic benefit in select cases [23]. However, the variability in patient responses and the lack of definitive large-scale randomized controlled trials necessitate caution before broadly advocating for PFO closure in migraine management [24,25].

Based on the available evidence, closure of PFO has been considered as a potential intervention for the management of migraine with aura in some patients. Meta-analysis studies have suggested that PFO closure may lead to improvements in migraine symptoms, particularly in individuals with migraine with aura. The studies showed a significant association with the burden reduction of migraine headaches. These studies indicated a significant improvement in migraine. It is hypothesized that the passage of microemboli or vasoactive chemicals through the PFO, bypassing the pulmonary filtration system, may contribute to the triggering of migraine attacks, particularly in patients with aura. Therefore, closure of the PFO may potentially interrupt this proposed pathological pathway, leading to a reduction in migraine frequency and severity [26,27].

This case underscores the imperative for a comprehensive and multidisciplinary evaluation of young patients presenting with migraine with aura, particularly when conventional therapeutic strategies fail. It accentuates the need for heightened clinical vigilance for PFO in this demographic to potentially mitigate the risk of more severe neurovascular complications, including cryptogenic stroke.

Future research directions should aim to elucidate the precise mechanisms linking PFO and migraine with aura, leveraging advanced imaging and biomarker studies. Moreover, prospective studies and randomized controlled trials are essential to establish the efficacy and safety of PFO closure in migraine prevention, thereby informing evidence-based clinical guidelines.

The confluence of migraine with aura and PFO in young patients presents a compelling intersection of neurology and cardiology, challenging clinicians to adopt an integrative and patient-centered approach to diagnosis and management. The evolution of our understanding and treatment modalities for these conditions will undoubtedly hinge on interdisciplinary collaboration and robust scientific inquiry.

Conclusions

Healthcare providers must recognize the potential link between migraine with aura and patent foramen ovale (PFO) in patients with findings suggestive of ischemic stroke, to implement practical diagnostic and therapeutic approaches. Considering cardiac assessments for PFO in young individuals experiencing persistent and challenging migraines with aura could prove advantageous. A collaborative, multidisciplinary approach encompassing neurology and cardiology is essential for the comprehensive management of such patients.

This case report highlights the importance of evaluating PFO as a contributing factor in young patients suffering from recurrent migraines, particularly those accompanied by an aura, and shows the need for further research to elucidate the relationship between PFO and migraines with aura, which will ultimately refine treatment modalities and enhance patient outcomes in this context.